Psychosocial impacts of the COVID-19 pandemic among settled women: A longitudinal study

Abstract Objective: to analyze the psychosocial impacts of the COVID-19 pandemic among Brazilian women from rural settlements. Method: this is a quantitative and longitudinal study conducted with 13 settled women. The data were collected between January 2020 and September 2021 using questionnaires on the perception of the social environment (quality of life, social support, self-efficacy), common mental disorder symptoms and sociodemographic aspects. The data were analyzed using descriptive statistics, cluster analysis and variance analysis. Results: intersecting vulnerability conditions were identified that possibly intensified the challenges arising from the pandemic. The Quality of Life physical domain fluctuated differently and inversely according to the mental disorder symptoms. As for the psychological domain, at the end of the segment, an increase over time was identified in the entire sample, as the women’s perception was better than before the pandemic. Conclusion: worsening of the participants’ physical health deserves to be highlighted and, probably, it can be related to the difficulty accessing health services in this period as well as to the fear of contamination. Despite this, the participants were emotionally resilient throughout the period, including signs of improvement in terms of psychological aspects, suggesting a possible effect of the community organization of the settlement.


Introduction
Prioritization of people in situations of social vulnerability is a recommendation in force in national and international health agendas and takes on even greater importance in the current COVID-19 pandemic context, both because they present a greater risk of illness and death and because of the social and health repercussions inherent to this process (1)(2)(3)(4)(5)(6)(7)(8) .
Women are also an important group to be considered in terms of public policies and of programs in the health and social protection areas, in view of the inequality and gender violence that mark society in most countries of the world and their repercussions in terms of health and quality of life (9) .
Recent studies, which approach gender inequality and poverty as overlapping aspects, have considered the specificities of different subgroups of women, namely: pregnant women; lactating women; women who have been victims of violence and those with any clinical condition or morbidity (1,3,(10)(11)(12) .
Among these subgroups, women who live in rural settlements deserve to be highlighted given the precarious infrastructure that generally characterizes these places, as well as the difficult access to essential resources such as health, education, basic sanitation and transportation (13)(14)(15) .
In addition to that, rural work, intensely and socially discredited and typical of this manual labor population, is added to the exercise of other roles culturally attributed to women, culminating in overload and intensifying the risks of worse living and health conditions in this group (13)(14)(15) .

Studies carried out in settlements from Kenya and
India during the pandemic period reported an increase in the burden of poverty, discrimination, violence and depressive and anxiety-related symptoms in this population, in addition to the excessive work of women, which also includes non-paid care activities (13,16) . In Brazil, a study found that settled women experience more distress in relation to issues such as precarious housing, itinerancy, social isolation and silencing (14) .
Recent studies on the repercussions of the pandemic on settled women have mainly emphasized the socioeconomic consequences and symptoms of mental disorders as outcome variables (13)(14)(15)(16) . Therefore, there is a need to expand the body of knowledge about the impacts of the pandemic, also considering more subjective, complex and relational aspects of the mental health of such women. Thus, the objective of the current study was to analyze the psychosocial impacts of the COVID-19 pandemic among Brazilian women from rural settlements.

Method Study design, locus and period
This is a quantitative and longitudinal study developed based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative checklist (17) . It was carried out in a settlement from the municipality of Ribeirão Preto, inland São Paulo, from January 2020 to September 2021.
In general, rural settlements in Brazil result from the tension between the Landless Workers Movement (Movimento de Trabalhadores Sem Terra, MST) and the federal agrarian reform agency (Instituto Nacional de Colonização e Reforma Agrária) with a view to the occupation of unproductive land by rural workers, considering the fundamental right of access to land (18) .
The subsistence culture, based on the agroforestry system and on preservation of the environment, is a basic premise of this movement and is added to the possibility of direct commercialization of products to the population, without intermediation of large traders, in opposition to the current logic of obtaining exaggerated profits (18) . Considering that the agrarian reform is not a priority agenda for most federal administrations, the issue of social (health, education, transportation, housing) and productive (technical assistance, machinery, capital) infrastructure is quite precarious in most Brazilian rural settlements (19) , in addition to being a characteristic of the settlement under study. With approximately 470 families settled in 1,541 hectares of land, the referred place generally comprises families with low socioeconomic conditions and who live in wooden houses without access to basic sanitation (piped water, sewage system), some covered with tarpaulins and distant from most of the basic resources that are concentrated in the urban area of the city.

Population and sample
The study population consisted of settled women, over 18 years of age and users registered at the settlement's health unit. The estimated population under responsibility of this unit is 3,744 inhabitants, of which approximately 1,910 are women, with 1,046 over 18 years of age.
The recruitment process was carried out through posters and pamphlets posted in the waiting room and offices, as well as via a direct approach carried out in home visits or in the waiting room of the aforementioned unit. The face-to-face approach was performed with 106 women, of which eight were excluded due to the clinical condition that precluded their participation and 45 refused the invitation, citing lack of time, lack of interest in the topic and concern about missing the appointment. www.eerp.usp.br/rlae 3 Oliveira JL, Almeida JCP, Pauli AJC, Moitinho MR, Fiorati RC, Souza J.

Data collection
In the first place, it should be noted that in Brazil, specifically in the state of São Paulo, during the pandemic period, the government decreed a quarantine with the specification of services that would or would not be allowed to work, as well as definition of criteria for classifying phases according to the number of people infected by COVID-19, hospitalizations and deaths, namely: phase 1 -red (high alert); phase 2 -yellow (control); phase 3 -yellow (flexibilization); phase 4 -green (partial opening) and phase 5 -blue (controlled normality) (20) .
In view of the above, as shown in Figure 2, the data collection follow-up took place in four stages: the first, between January 13 th and March 17 th , 2020 (pre-pandemic); the second, between June 1 st and July 31 st , 2020 (red phase); the third, between September 22 nd and November 13 th , 2020 (yellow phase) and the fourth, between August 6 th and September 10 th , 2021 (blue phase).
Thus, considering the women who accepted the invitation to participate, the convenience sample had 53 women in the first follow-up phase, as shown in Figure   1. In the second, 28 women; in the third, 19 and in the fourth and last phase, 13, constituting the final sample of the current research. in a scale from 4 to 20, which can be transformed into a scale from 0 to 100 through the syntax developed by the authors (21) . The higher the score, the better the QoL perception (21) . The validated Portuguese version met the criteria for internal consistency (Cronbach's alpha  (22) . In Brazil, the results for validation indicated favorable test-retest reliability and a high internal consistency level, similarly and coherently with the data provided in the scale elaboration study (22) . In the current study, the short version of the instrument, SSQ-6, was used, consisting of six items, which can be considered a practical alternative to the full version, including items related to acceptance, affection and affirmation of personal value (22) .
The Self-Report Questionnaire -SRQ-20 was developed by the World Health Organization to assess Common Mental Disorders (CMD) in developing countries (23) . The original version has 24 items, the first 20 of which are evaluators for non-psychotic disorders and four items for psychotic disorders. In the Brazilian version, as its adaptation was carried out in a Primary Health Care context, only the first 20 items are used (23) . The questionnaire has 20 "yes" or * WHO = World Health Organization; † Emergency aid = 18 installments in Reais (R$), from R$ 300.00 to R$ 600.00 (in April/2020 equivalent to 63.34 US$ and 126.68 US$, respectively), paid to the families in socioeconomic vulnerability conditions "no" questions about emotional and physical symptoms associated with psychiatric conditions. Suspected cases of mental disorder are those in which there are more than eight positive answers (23) . Sensitivity was 83% and specificity, 80%.
The Perceived General Self-Efficacy Scale (PGSES) assesses the general sense of self-efficacy perceived by the individual, aiming to predict coping with daily difficulties, as well as adaptation after experiencing stressful life events (24) . It is a Likert-type scale with ten items on a scale from 1 to 4. The total score is calculated by adding up all items, varying from 10 to 40, with higher scores indicating greater self-efficacy (24) .
The scale was validated in Brazil in a study carried out with 283 individuals with a mean age of 22 years old (Cronbach's alpha: 0.81) (24) .

Data analysis
The data were analyzed using descriptive statistics To interpret the meaning of each principal component, the sign and the relative dimension of the coefficients of the linear functions were considered as an indication of the weight to be attributed to each variable. After standardizing the data (null mean and unit variance), the first two principal components (PC1 and PC2), whose eigenvalues were above 1 according to the criterion established in a previous study (26) , were considered in this study.
In order to corroborate the influence of time on the behavior of the group identified in the multivariate analysis After performing the Shapiro-Wilk test, the data that did not present normality were transformed and, after such transformation, all data showed normality (p>0.05).
p>0.05 was obtained in the Levene test to verify homogeneity of variances and, subsequently, Tukey's test was performed to compare the means.

Ethical aspects
The project was submitted to the Research Ethics

Characteristics of the participants
Regarding the participants' sociodemographic profile, it is noted that most of them were at least 40 years old (median of 49, minimum of 19 and maximum of 59), self-declared as belonging to the black or mixed races, not living in a stable union and earning monthly family incomes of up to two minimum wages ( Table 1).
The median number of children was 2 (minimum of 0 and maximum of 4). Two women had no diagnosed chronic diseases. In the period analyzed, four of them tested positive for COVID-19 and three did not receive emergency aid (Table 1)

Discussion
The sociodemographic profile of the studied sample emphasized the participants' conditions of social vulnerability. As shown in the results, two reported family incomes of more than two minimum wages, four had paid work and ten met the criteria for receiving emergency aid, which denotes a precarious living condition that was certainly intensified during the pandemic period, in view of the exponential increase in unemployment and the cost of living, which lead to even greater difficulties acquiring basic items by the poorest people (12) . In addition, studies carried out with settlement populations identified that food and financial insecurity was mentioned by the participants (13)(14)(15) , that is, the lower-income population was the one that suffered the most from the impacts of the pandemic (11) .
The fact that most of the participants declared themselves as black-skinned highlights the complexity of the gender, race and class intersection that significantly exacerbates the inequalities and vulnerabilities experienced by these women. In addition to that, many of them were home providers themselves and the main caregivers of children and aged people, exposing them disproportionately to the negative consequences of the pandemic, factors also evidenced in previous studies (9)(10)12) .  Therefore, the 30.8% prevalence of infected people in the studied sample stands out, which is certainly related to such situations (4,8) . In view of the aforementioned aspects, it is inferred that the impacts of such morbidity may have been even worse when considering these women's possible apprehension in contaminating other family members, especially considering the fact that they are the main caregivers, as previously reported. In addition to that, the positive diagnosis results in distancing from work activities, which may consequently have affected their incomes with paid jobs. Furthermore, the possible sequelae may have had a substantial impact on their quality of life, as well as negatively affect their health, as pointed out by previous studies (1,12) .
In the results, it was identified that the women were well-discriminated between them in psychosocial terms, especially with regard to the perception of the social environment (environmental and relational aspects). In this sense, those who perceived this environment more positively were less vulnerable to emotional distress in the periods analyzed. This result corroborates a previous study that evaluated the impacts of COVID-19 on women's mental health in Hong Kong and identified that those with better QoL and self-efficacy perceptions presented negative emotional symptoms to a lesser extent (12) .
Considering that mental health encompasses complex It is worth noting that, in the cluster analysis, satisfaction with the support was identified as an important component for discrimination of the groups.
However, the number of supporters exerted no significant effect on the outcomes considered. It is understood that this result can reflect the role of moderation and not necessarily the direct effect of the social support variable, as pointed out in previous studies, especially in those that observed perceived stress as outcome (32)(33) . In addition to that, research studies on social support tend to consider the supporters' attributes (family, friends, neighbors, others), the type of support (emotional, informational, instrumental) and the level of satisfaction with it (satisfied, dissatisfied) (33)(34) to a greater extent than the number of supporters itself. On the other hand, a previous study in which the number of supporters was evaluated also identified that the satisfaction item was more determinant of psychosocial protection than the number of supporters (35) . In this sense, the current result emphasizes the importance of satisfaction with the support as a construct to be prioritized in the implementation of mental health promotion strategies.
In relation to the impact of the different phases of the pandemic on the psychosocial aspects analyzed, the physical and psychological domains of QoL presented significant results.
In the psychological domain, there was an increase in scores over time in the sample as a whole. This result differs both from what was expected for a pandemic period and from the results of previous studies carried out with the general population of different countries (36)(37)(38) . Thus, in relation to the current study, it is worth noting the following: firstly, the specificities of the sample in terms of gender and social condition; secondly, the long-term character in relation to longitudinality and, also, the fact that data collection took place via telephone contacts.
Regarding the specificities of the sample, it is hypothesized that, while the psychological domain encompasses issues related to positive and negative feelings, self-esteem, body image and appearance, thoughts, learning, concentration, memory and personal beliefs (21) This QoL domain includes questions   about pain and discomfort, energy and fatigue, sleep and rest, mobility, activities of daily living, dependence on medication or treatments, and work capacity (21) .
Thus, considering the high prevalence of COVID-19 in the sample studied, the results of decreased QoL in this domain among the most vulnerable women can be considered unsurprising.
It is important to note that access to Brazilian health services for the entire population during the pandemic period was hampered due to canceled consultations and exams and limited care, only available in emergency cases. In the specific case of the sample studied, there was an aggravating factor, as the health unit located in the settlement was closed and the professionals were relocated to the unit in the urban area. Thus, access was made even more difficult both due to the pandemic issue and to the limitations already imposed and to the distance and displacement difficulty.
Worse physical health outcomes also reflect issues related to the vulnerability and poverty cycle that further perpetuates and expands life-and health-threatening conditions. In this sense, the poorest population, with more precarious access to health services and who are unable to carry out the necessary follow-ups, generally have worse health outcomes, with negative consequences for work, income and quality of life in general (4)(5)(7)(8) .
Although the other aspects did not exert a significant impact over time, a well-demarcated division of groups was identified, so that women with multiple CMD symptoms also had worse results in terms of the psychosocial aspects analyzed during the entire follow-up period. It should be noted that, in general, previous studies report that large-scale catastrophes are commonly accompanied by worsening in the population's mental health conditions (3,5,38) ; therefore, groups already vulnerable for other reasons should have additional priority in public health and social protection policies, especially during these periods.
In this sense, it is understood that settled women are an extremely important group to consider when thinking about policies and strategies for health promotion in general. This is because, in addition to vulnerability to socioeconomic, racial and gender issues, we must add insecurity regarding housing and the difficulties arising from living in a settlement, such as food insecurity, unemployment, and precarious access to health, education, sanitation and transportation services (13)(14)(15) .
In addition, the agricultural work developed by these women requires greater physical effort, which consequently affects their functional capacity, an item from the physical domain. Furthermore, this work burdens mental health, as production instability generates concerns, fear and anxiety about their livelihood, which were intensified in the pandemic period, as reported by some participants.
The findings of the current study showed that, despite this overlapping of vulnerabilities, the difference in the perception of the social environment proved to be a protective factor in relation to emotional distress, which has important implications in terms of the clinical practice, as health actions in general, which also make it possible to improve the users' social environment, may exert an important impact on their mental health outcomes.
Thus, in terms of recommendations for the practice, in addition to the issues of improving the physical and psychological domain already discussed, the relevance of strategies focused on social support and self-efficacy of vulnerable women stands out. Regarding social support, its role as a protective factor for better results in mental health issues has been consolidated in the literature (35,(39)(40) .
As it is an individual's belief in their ability to deal with a wide variety of demands and face new situations, selfefficacy has also been associated with positive mental health outcomes (12,40) .
In addition to that, previous studies specifically developed during the pandemic period have identified that social support feeds back the perception of selfefficacy, as a quality support network contributes to sharing experiences, which in turn can result in diverse information, self-knowledge building and individual understanding, in addition to access to different coping strategies, management and emotional venting (40)(41)(42) .
These factors become even more important when considering the fact that previous research studies indicate that the settled women's mental distress is intensified due to the fact that they often have to silence their feelings because they do not feel welcomed to share them so much with their support network and with health professionals (13)(14) . Thus, it is understood that, since health professionals, specifically nurses, are